Anaesthetic Problems Research Articles

A ketamine–propofol admixture does not reduce the pain on injection compared with a lidocaine–propofol admixture

Propofol injection pain is a well-known problem in pediatric anesthesia. Premixture of lidocaine with propofol although effective does not abolish injection pain in all children. Promising results have been reported with pretreatment of the vein with ketamine. The purpose of this prospective, double-blind randomized, clinical trial with active control was to evaluate the efficacy of premixing propofol with ketamine in the prevention of injection pain in children. After ethics committee and parental approval and children's assent, 116 children, aged 1-12 years, were randomly allocated to receive an IV induction dose of admixture of racemic ketamine 0.5 mg x ml(-1) (ketamine group) or lidocaine 1 mg x ml(-1) in propofol 10 mg x ml(-1) (lidocaine group). The outcome measures were signs and symptoms of injection pain (primary outcome: the incidence of injection pain), hemodynamic and respiratory parameters, and adverse effects during anesthesia induction (secondary outcomes). Patients' characteristics were similar in the two groups. Fewer children (13/58) in the lidocaine group than in the ketamine group (26/58) (mean difference 23%, 95% CI for difference 6-40%, P = 0.018) developed pain on injection of propofol. There were no differences in hemodynamic parameters between the two groups. One child in the lidocaine group developed laryngospasm, but no other adverse events were recorded. Injection pain was twice as common with ketamine-propofol admixture than with lidocaine-propofol admixture.

Operative steps in management of benign nerve sheath tumors

Benign peripheral nerve sheath tumors include the neurofibroma, schwannoma, and their plexiform variants. Operative management begins with an assessment of the relative risks associated with surgery compared with observation. The risks of observation include the risk of malignancy, the progression of symptoms, risk of delayed surgery, and ongoing patient suffering. The risks of surgery include anesthetic problems, wound complications, and neurological injury. New neurological deficits have been reported to occur in approximately 10 to 15% of surgically treated cases. In general, surgery is recommended for symptomatic or progressive lesions. Although the surgical approach will vary depending on the location, type, and extent of tumor, adherence to certain principles will facilitate success. Adequate visualization and successful removal will be achieved with detailed anatomical knowledge, an adequate extensile exposure to visualize the proximal and distal tumor extent, circumferential dissection of the tumor, microsurgical dissection under appropriate magnification, and meticulous hemostasis throughout the procedure.

PR39P TREATMENT OF MITTEN HAND DEFORMITY IN A LONG TERM SURVIVOR OF EPIDERMOLYSIS BULLOSA

EB is a recessive condition caused by a defect in collagen 7 production, such that epithelial cells do not adhere adequately to the underlying basement membranes. Minor mechanical trauma and stress forces will cause recurrent blistering of the skin and mucosal surfaces, which heal by scarring.The hand suffers particularly badly, and a characteristic mitten deformity of scar tissue is a common stigmata of the disease.We report a 51 year old survivor of EB with a bilateral mitten hand deformity that had been present since the age of 6 years.Extensive surgical release of the dominant left hand was undertaken, resurfacing the created defects with split skin grafts under regional anaesthesia. Fingers that had been buried for 45 years were straightened and held in place with k wires whilst the grafts were vascularising.Extensive post operative physiotherapy and splinting were undertaken, with functional improvement to the extent that the patient was able to hold a pen and write. Skin graft donor sites healed uneventfully.Extensive release of mitten hand deformity in long term survivors of EB is a worthwhile surgical procedure with good functional results. The problems of surgery and anaesthesia in this condition are discussed. Release of the second hand is planned.

Ethics in research

This review will examine research ethics in the context of globalization of clinical trials and recent rapid developments in bioscience. It will focus on international ethical guidelines and the functions of research ethics review boards in research governance. Consent issues in genetic research, which must comply with privacy laws by protecting confidentiality and privacy of personal health data, will be discussed. There has been a rapid expansion of genomic and proteonomic research and biotechnology in the last decade. International ethical guidelines have been updated and the bioscience industry has developed ethics policies. At the same time, problems in academic anesthesia in the US and UK have been identified, leading to recommendations to train physician-scientists in anesthesia to stimulate research activity in the future. Anesthesiologists are joining interdisciplinary research teams and the concept of evidence-based translational research is emerging. Anesthesiologists are moving towards participation in interdisciplinary research teams. They are well placed to speed the translation of research discovery into clinical practice and provide evidence-based perioperative care. This review provides the ethical framework that anesthesiologists will need to meet the challenges of this changing pattern of practice.

Victims of Our Own Success or Quo Vadis Pediatric Anesthesia?

Victims of Our Own Success or Quo Vadis Pediatric Anesthesia?

The Effect of Fentanyl and Remifentanil on the Side Effects after Sevoflurane Anesthesia in Children Undergoing Herniorrhaphy

Background: Emergence agitation is one of the major problems in pediatric anesthesia. The aim of this study was to compare the effect of remifentanil and fentanyl on the incidence of emergence agitation, postoperative pain and postoperative vomiting after administering anesthesia with sevoflurane. Methods: Thirty ASA physical status 1−2 children, aged 12−60 months undergoing a unilateral inguinal herniorrhaphy were randomized to receive either remifentanil (group R, bolus 0.5μg/kg; infusion 0.2μg/kg/min) or fentanyl (group F, 1μg/kg) after thiopental sodium induction. All patients received sevoflurane for maintenance of anesthesia. Heart rate and blood pressure were measured at baseline (T0), preintubation (T1), postintubation (T2) and 5 minutes after intubation (T3). The agitation score, pain score and incidence of postoperative vomiting were assessed upon arrival at the recovery room (P0), 30 minutes thereafter (P1) and 3 hours after discharge from the recovery room (P2). Results: The agitation score were higher in group R at P0 (P ＜ 0.05). The pain score was higher in group R at P0, P1 and P2 (P ＜ 0.05). Postoperative vomiting was present only in one patient in group F. Conclusions: Adjuvant use of fentanyl during sevoflurane anesthesia revealed advantages over the use of remifentanil concerning the incidence of postoperative agitation and pain without any prolongation of recovery time. (Korean J Anesthesiol 2007; 53: 609～14)

Intraoperative Apnea: Medication Error with Disclosure (Simulation Case Scenario)

Intraoperative Apnea: Medication Error with Disclosure (Simulation Case Scenario)

The use of nitrous oxide in paediatric anaesthetic practice in the United Kingdom: a questionnaire survey*

Nitrous oxide pollution is common in paediatric anaesthetic practice. A questionnaire was sent to all UK members of the Association of Paediatric Anaesthetists requesting details of three areas of their paediatric practice relating to nitrous oxide: attitudes to its use; current usage; and availability of alternatives. Replies were received from 296 (68%) consultants. Of these, 169 (57%) stated that their use of nitrous oxide had decreased over the last 5 years. One hundred and fifty-eight (54%) considered theatre pollution a problem in paediatric anaesthesia. One hundred and sixty-nine (57%) reported that in normal circumstances potential deleterious effects on patients influenced their use of nitrous oxide, whilst only 70 (24%) felt potential effects on staff influenced usage. Fifty-five (18%) felt there should be some restriction in the availability of nitrous oxide.

Intubation transorbitaire : une intubation difficile prévisible en chirurgie céphalique

Management of the difficult adult airway is a crucial problem in anaesthesia. It is the first cause of anaesthetic mortality and morbidity. We report here the case of a patient who could only be intubated through the orbital cavity. We discuss our technique of intubation compared to the other rare procedures described in the literature. We also focus on our anaesthetic protocol and the interest of preserving spontaneous ventilation for intubation. Use of short acting anaesthetic drugs can help to achieve such conditions.

Pioneer British Anaesthetists, Vol. IX in the Careers in Anesthesiology series.

Pioneer British Anaesthetists, Vol. IX in the Careers in Anesthesiology series.

Pathophysiologie rheumatischer Fußdeformitäten und operatives Patientenhandling

Summary Rheumatoid arthritis is a systemic disease that often (85–100% of patient) affects the foot and ankle. In relation to the stage of disease there are characteristic deformities. Clinical assessment of both lower limbs is important, because factors like valgus deformity of the knee can cause malposition of the foot and ankle. In the early stage, patients present with joint effusion which causes destruction of the cartilage (“stiff-type”) and distends ligaments and capsules (“loosetype”). Medial and lateral ankle tendons become destroyed and insufficient. Reduction of walking distance, pain, instability and difficulties with footwear lead to a lack of life quality. The talonavicular joint and the rheumatoid forefoot destruction are in most cases the center problem of the foot deformity. Conservative treatment like orthotic shoe devices should be used in the early stage and are concomitantly used after surgical treatment. Rheumatoid arthritis is a systemic disease that requires an attentive handling perioperatively. Management of the special medication, concomitant diseases, skin, atlantoaxial instability, intraoperative bedding, anesthetic problems and higher risk for infection as well as the postoperative mobilization require special care and expertise.

Introduction of the Anesthesia Patient Data Management System and Problems in the Use at Tokai University Hachioji Hospital

開院に伴い, 当院の手術室に麻酔患者データ管理システムを導入して4年が経過した. 患者情報検索が容易になるなど作業環境の向上が図られる一方で, さまざまな障害も発生している. 障害は (1)ハードの障害, (2)ソフトの障害, (3)運用上の障害, (4)操作のミスによる障害, (5)その他の障害に分類される. 導入当初は操作が不慣れな影響もあり操作のミスによるものが多かったが, 最近では減少しソフトの障害が多くを占めている. ソフトの障害の原因としては, カスタマイズしたことで麻酔記録のデータが多くなり, メモリ容量が小さくなることや, 院内電子カルテと麻酔患者データ管理システムとの互換性がほとんどないことがあげられる. しかし実際は, 障害の内訳を厳密に区別することは難しい.

Anesthetic Experience of Acquired Distal Tracheoesophageal Fistula: A case report

A tracheoesophageal fistula (TEF) was detected in a woman who received chemotherapy for acute lymphoblastic leukemia. The fistula biopsy confirmed the aspergillus infection. A large fistula was located at the lateral wall of the carina involving the proximal left main bronchus, and the orifice of left main bronchus was almost completely obstructed by white mass-like plaque. Primary repair was planned using the right thoracotomy approach. We originally planned to selectively intubate the left lung with the aid of fiberoptic bronchoscope without success. Therefore, we selectively intubated the right lung. Hypoxemia developed during surgery and the level of oxygenation was improved by selectively intubating the left bronchus from the surgical field once the defect had been exposed. We review the ventilation technique and anesthetic problems encountered in patients with a large distal TEF.

The contribution of severe pre-eclampsia to maternal death on the operating table (D.O.T.) in Enugu: a five years review, problems proffered solutions

Background: Maternal death on operating table is a most distressing situating in obstetric practice.Methods: A review of records of maternal deaths on table January 1995 and December 1999 at the NAUTH Enugu.Results: There were 18 maternal deaths following caesarean section at the University of Nigeria teaching Hospital (N.A.U.T.H), Enugu. Nine (50%) of the these maternal deaths occurred on the operating table (DOT). Severe pre-eclampsia was responsible for 66.7% (6 out of 9). Intraoperative surgical difficulty in the form of uncontrollable hemorrhage occurred in one of the nine cases. Discussion and conclusion: The difficulty of intubations and other problems of general anaesthesia posed by these patients thought to be contributory factors are analyzed. Suggestion is made as to alternative methods of an aesthesia for this risky group of patients especially in the setting of a developing nation where skilled anesthetists are in short supply.Keywords: maternal death on the table, pre-eclampsiaTropical Journal of Medical ResearchVol. 9(1) 2005: 18-20

Day care after operations for hernia or varicose veins: A controlled trial

Alternative systems of care after operations for varicose veins or hernia were compared in a total of 360 selected patients, of whom 121 were allocated to be managed in an acute ward for 48 h, 122 in a convalescent hospital for 48 h and 117 to be discharged directly home to the care of the district nursing sister and general practitioner. There were no deaths or major complications. Anaesthetic or surgical problems caused 5 patients (3 convalescent and 2 day care) to be retained in hospital on the day of operation. Minor complications were recorded in approximately one-third of the patients. The majority of these were effectively dealt with by the district nursing sister and only one-third of the complications needed the attention of the general practitioner. Two of the ward patients and 1 of the convalescent patients required readmission to hospital (1 per cent in all). No significant difference was demonstrated in the medical outcome between the three groups after operation. Day care was the most economical of the three systems of care. Inquiry into the patients' opinions elicited the highest proportion of favourable responses in the day care group.

Renal Transplantation in a Patient Affected by Mounier-Kuhn Syndrome

Tracheobronchomegaly, also called Mounier-Kuhn syndrome, consists in dilatation of the trachea and major bronchi because of atrophy or absence of their elastic fibers and smooth muscle cells. Standard chest radiography often does not permit diagnosis because only lateral imaging, obtained with X-rays or chest CT scan, shows the true degree of tracheal dilatation. Surgery has no role in tracheomegaly, except for the complications of tracheal stenosis or pneumothorax. The present work reports cadaveric renal transplantation in a 43-year-old woman affected by end-stage renal disease and suffering from congenital tracheobronchomegaly diagnosed during the first decade of life. No surgical or anesthetic problems were encountered during the immediate perioperative period. The patient did not require pulmonary physiotherapy. Antibiotic prophylaxis was given for 10 days. No pulmonary infection developed, and the patient was discharged from the hospital asymptomatic with normal renal function at 25 days after the transplant. Four months later, the patient experienced bronchitis with cough and fever. Antibiotic therapy was performed with totally resolution of symptoms. At 8 months of follow-up after kidney transplantation, the patient is asymptomatic with normal renal function.

General anesthesia for patient with type III homocystinuria (tetrahydrofolate reductase deficiency)

Homocystinuria, a rare autosomal recessive genetic disease, is generally classified into 3 types (types I-III). Extremely rare type III is from a defect of the enzyme tetrahydrofolate reductase which converts homocysteine to methionine. The anesthetic problem of type III homocystinuria is the elevation of serum homocysteine and the deficiency of essential amino acid methionine, which result in the perioperative thromboembolic events and nitrous oxide–induced neurological impairment. We provided successful anesthetic management for a patient with type III homocystinuria, during which we were careful to take measures against perioperative thromboembolism and did not use nitrous oxide.

McArdle's disease and anaesthesia: Case reports. Review of potential problems and association with malignant hyperthermia

McArdle's disease of isolated deficiency in glycogen degradation in skeletal muscles has the potential of creating perioperative anaesthesiological problems; such as hypoglycaemia, rhabdomyolysis, myoglobinuria, acute renal failure and possibly malignant hyperthermia. Eight patients with McArdle's disease were asked about previous surgery, anaesthesia and perioperative problems, and available hospital records were reviewed. Existing literature was reviewed for reports on McArdle's disease and anaesthesia. The eight patients had 35 anaesthesias (23 general anaesthesias, three regional anaesthesias and nine local anaesthesias). Perioperative problems of a non-specific nature were mentioned in three cases of general anaesthesia: two with postoperative nausea/vomiting, and one with an episode of tachycardia and low blood pressure. Three patients were tested for malignant hyperthermia (MH) using the in vitro contracture test (IVCT); two of them with a positive result. The literature search revealed seven case reports of McArdle's disease and anaesthesia. Apart from one report of hyperthermia, pulmonary oedema and rhabdomyolysis; probably not associated with MH, no problems were encountered from the literature search. McArdle's disease does not seem to cause severe perioperative problems in routine anaesthetic care. However, measures for preventing muscle ischaemia and rhabdomyolysis should be kept in mind, as well as the potential for these patients to develop postoperative fatigue, myoglobinuria and renal failure. Although no clinical association with malignant hyperthermia has been established, many of these patients can have a positive in vitro contracture test, and simple prophylactic measures, as with malignant hyperthermia, may be recommended if otherwise not contraindicated.

Warning of previous anaesthetic problems

Warning of previous anaesthetic problems

The upper airway in Weaver syndrome

Weaver syndrome is a rare disorder of unknown etiology characterized by skeletal overgrowth, distinctive craniofacial and digital abnormalities, and advanced bone age. The prime anesthetic problem reported in children with Weaver syndrome is difficulty with tracheal intubation, resulting in part from relative micrognathia, short neck, and an anterior and cephalad position of the larynx. In this report, the authors describe their experience with two children diagnosed with Weaver syndrome who presented for dental surgery. Contrary to previous reports, tracheal intubation was accomplished with relative ease, suggesting that difficulty in intubation in Weaver syndrome may be age-related, diminishing with advancing age and growth of the mandible, as has been reported for other micrognathic syndromes such as Pierre Robin sequence.